METHODS: PLHIV from a regional observational cohort without DM prior to antiretroviral therapy (ART) initiation were included in the analysis. DM was defined as having a fasting blood glucose ≥126 mg/dL, glycated haemoglobin ≥6.5%, a two-hour plasma glucose ≥200 mg/dL, or a random plasma glucose ≥200 mg/dL. A Cox regression model, stratified by site, was used to identify risk factors associated with DM.
RESULTS AND DISCUSSION: Of the 1927 participants included, 127 were diagnosed with DM after ART initiation. Median follow-up time from ART initiation to DM diagnosis was 5.9 years (interquartile range (IQR): 2.8 to 8.9 years). The crude incidence rate of DM was 1.08 per 100 person-years (100 PYS), 95% confidence interval (CI) (0.9 to 1.3). In the multivariate analysis, later years of follow-up (2011 to 2013: HR = 2.34, 95% CI 1.14 to 4.79, p = 0.02; and 2014 to 2017: HR = 7.20, 95% CI 3.27 to 15.87, p 50 years: HR = 4.19, 95% CI 2.12 to 8.28, p 30 kg/m2 (HR = 4.3, 95% CI 1.53 to 12.09, p = 0.006) compared to BMI <18.5 kg/m2 , and high blood pressure (HR = 2.05, 95% CI 1.16 to 3.63, p = 0.013) compared to those without high blood pressure, were associated with developing DM. The hazard was reduced for females (HR = 0.47, 95% CI 0.28 to 0.80, p = 0.006).
CONCLUSIONS: Type 2 DM in HIV-infected Asians was associated with later years of follow-up, high blood pressure, obesity and older age. This highlights the importance of monitoring and routine screening for non-communicable diseases including DM as PLHIV age.
METHODS: Adults living with HIV enrolled in a regional observational cohort in Asia who had initiated combination antiretroviral therapy (cART) were included in the analysis. Factors associated with new TB diagnoses after cohort entry and survival after cART initiation were analysed using Cox regression, stratified by site.
RESULTS: A total of 7355 patients from 12 countries enrolled into the cohort between 2003 and 2016 were included in the study. There were 368 reported cases of TB after cohort entry with an incidence rate of 0.99 per 100 person-years (/100 pys). Multivariate analyses adjusted for viral load (VL), CD4 count, body mass index (BMI) and cART duration showed that CTX reduced the hazard for new TB infection by 28% (HR 0.72, 95% CI l 0.56, 0.93). Mortality after cART initiation was 0.85/100 pys, with a median follow-up time of 4.63 years. Predictors of survival included age, female sex, hepatitis C co-infection, TB diagnosis, HIV VL, CD4 count and BMI.
CONCLUSIONS: CTX was associated with a reduction in the hazard for new TB infection but did not impact survival in our Asian cohort. The potential preventive effect of CTX against TB during periods of severe immunosuppression should be further explored.
HEALTH IMPACT OF DRUG POLICY BASED ON ENFORCEMENT OF PROHIBITION: The pursuit of drug prohibition has generated a parallel economy run by criminal networks. Both these networks, which resort to violence to protect their markets, and the police and sometimes military or paramilitary forces that pursue them contribute to violence and insecurity in communities affected by drug transit and sales. In Mexico, the dramatic increase in homicides since the government decided to use military forces against drug traffickers in 2006 has been so great that it reduced life expectancy in the country. Injection of drugs with contaminated equipment is a well-known route of HIV exposure and viral hepatitis transmission. People who inject drugs (PWID) are also at high risk of tuberculosis. The continued spread of unsafe injection-linked HIV contrasts the progress that has been seen in reducing sexual and vertical transmission of HIV in the last three decades. The Commission found that that repressive drug policing greatly contributes to the risk of HIV linked to injection. Policing may be a direct barrier to services such as needle and syringe programmes (NSP) and use of non-injected opioids to treat dependence among those who inject opioids, known as opioid substitution therapy (OST). Police seeking to boost arrest totals have been found to target facilities that provide these services to find, harass, and detain large numbers of people who use drugs. Drug paraphernalia laws that prohibit possession of injecting equipment lead PWID to fear carrying syringes and force them to share equipment or dispose of it unsafely. Policing practices undertaken in the name of the public good have demonstrably worsened public health outcomes. Amongst the most significant impacts of pursuit of drug prohibition identified by the Commission with respect to infectious disease is the excessive use of incarceration as a drug-control measure. Many national laws impose lengthy custodial sentences for minor, non-violent drug offenses; people who use drugs (PWUD) are over-represented in prison and pretrial detention. Drug use and drug injection occur in prisons, though their occurrence is often denied by officials. HIV and hepatitis C virus (HCV) transmission occurs among prisoners and detainees, often complicated by co-infection with TB and in many places multidrug-resistant TB, and too few states offer prevention or treatment services in spite of international guidelines that urge comprehensive measures, including provision of injection equipment, for people in state custody. Mathematical modelling undertaken by the Commission illustrates that incarceration and high HCV risk in the post-incarceration period can contribute importantly to national HCV incidence amongst PWID in a range of countries with varying levels of incarceration, different average prison sentences, durations of injection, and OST coverage levels in prison and following release. For example, in Thailand where PWID may spend nearly half their injection careers in prison, an estimated 63% of incident HCV infection could occur in prison. In Scotland, where prison sentences are shorter for PWUD and OST coverage is relatively high in prison, an estimated 54% of incident HCV infection occurs in prison, but as much as 21% may occur in the high-risk post-release period. These results underscore the importance of alternatives to prison for minor drug offences, ensuring access to OST in prison, and a seamless link from prison services to OST in the community. The evidence also clearly demonstrates that drug law enforcement has been applied in a discriminatory way against racial and ethnic minorities in a number of countries. The US is perhaps the best documented but not the only case of racial biases in policing, arrest, and sentencing. In 2014, African American men were more than five times more likely than whites to be incarcerated in their lifetime, though there is no significant difference in rates of drug use among these populations. The impact of this bias on communities of people of color is inter-generational and socially and economically devastating. The Commission also found significant gender biases in current drug policies. Of women in prison and pretrial detention around the world, a higher percentage are detained because of drug infractions than is the case for men. Women involved in drug markets are often on the bottom rungs – as couriers or drivers – and may not have information about major traffickers to trade as leverage with prosecutors. Gender and racial biases have marked overlap, making this an intersectional threat to women of color, their children, families, and communities. In both prison and the community, HIV, HCV and TB programmes for PWUD – including testing, prevention and treatment – are gravely underfunded at the cost of preventable death and disease. In a number of middle-income countries where large numbers of PWUD live, HIV and TB programmes for PWUD that were expanded with support from the Global Fund to Fight AIDS, TB and Malaria have lost funding due to changes in the Fund’s eligibility criteria. There is an unfortunate failure to emulate the example of Western European countries that have eliminated unsafe injection-linked HIV as a public health problem by sustainably scaling up prevention and care and enabling minor offenders to avert prison. Political resistance to harm reduction measures dismisses strong evidence of their effectiveness and cost-effectiveness. Mathematical modeling shows that if OST, NSP and antiretroviral therapy for HIV are all available, even if the coverage of each of them is not over 50%, their synergy can lead to effective prevention in a foreseeable future. PWUD are often not seen to be worthy of costly treatments, or they are thought not to be able to adhere to treatment regimens in spite of evidence to the contrary. Lethal drug overdose is an important public health problem, particularly in light of rising consumption of heroin and prescription opioids in some parts of the world. Yet the Commission found that the pursuit of drug prohibition can contribute to overdose risks in numerous ways. It creates unregulated illegal markets in which it is impossible to control adulterants of street drugs that add to overdose risk. Several studies also link aggressive policing to rushed injection and overdose risk. People with a history of drug use, over-represented in prison because of prohibitionist policies, are at extremely high risk of overdose when released from state custody. Lack of ready access to OST also contributes to injection of opioids, and bans on supervised injection sites cut off an intervention that has proven very effective in reducing overdose deaths. Restrictive drug policies also contribute to unnecessary controls on naloxone, a medicine that can reverse overdose very effectively. Though a small percentage of PWUD will ever need treatment for drug dependence, that minority faces enormous barriers to humane and affordable treatment in many countries. There are often no national standards for quality of drug dependence treatment and no regular monitoring of practices. In too many countries, beatings, forced labor, and denial of health care and adequate sanitation are offered in the name of treatment, including in compulsory detention centres that are more like prisons than treatment facilities. Where there are humane treatment options, it is often the case that those most in need of it cannot afford it. In many countries, there is no treatment designed particularly for women, though it is known that women’s motivations for and physiological reactions to drug use differ from those of men. The pursuit of the elimination of drugs has led to aggressive and harmful practices targeting people who grow crops used in the manufacture of drugs, especially coca leaf, opium poppy, and cannabis. Aerial spraying of coca fields in the Andes with the defoliant glyphosate (N-(phosphonomethyl glycine) has been associated with respiratory and dermatological disorders and with miscarriages. Forced displacement of poor rural families who have no secure land tenure exacerbates their poverty and food insecurity and in some cases forces them to move their cultivation to more marginal land. Geographic isolation makes it difficult for state authorities to reach drug crop cultivators in public health and education campaigns and it cuts cultivators off from basic health services. Alternative development programmes meant to offer other livelihood opportunities have poor records and have rarely been conceived, implemented, or evaluated with respect to their impact on people’s health. Research on drugs and drug policy has suffered from the lack of a diversified funding base and assumptions about drug use and drug pathologies on the part of the dominant funder, the US government. At a time when drug policy discussions are opening up around the world, there is an urgent to bring the best of non-ideologically-driven health science, social science and policy analysis to the study of drugs and the potential for policy reform.
POLICY ALTERNATIVES IN REAL LIFE: Concrete experiences from many countries that have modified or rejected prohibitionist approaches in their response to drugs can inform discussions of drug policy reform. A number of countries, such as Portugal and the Czech Republic, decriminalised minor drug offenses years ago, with significant savings of money, less incarceration, significant public health benefits, and no significant increase in drug use. Decriminalisation of minor offenses along with scaling up low-threshold HIV prevention services enabled Portugal to control an explosive unsafe injection-linked HIV epidemic and likely enabled the Czech Republic to prevent one from happening. Where formal decriminalisation may not be an immediate possibility, scaling up health services for PWUD can demonstrate the value to society of responding with support rather than punishment to people who commit minor drug infractions. A pioneering OST program in Tanzania is encouraging communities and officials to consider non-criminal responses to heroin injection. In Switzerland and the city of Vancouver, Canada, dramatic improvements in access to comprehensive harm reduction services, including supervised injection sites and heroin-assisted treatment, transformed the health picture for PWUD. Vancouver’s experience also illustrates the importance of meaningful participation of PWUD in decision-making on policies and programmes affecting their communities.
CONCLUSIONS AND RECOMMENDATIONS: Policies meant to prohibit or greatly suppress drugs present a paradox. They are portrayed and defended vigorously by many policy-makers as necessary to preserve public health and safety, and yet the evidence suggests they have contributed directly and indirectly to lethal violence, communicable disease transmission, discrimination, forced displacement, unnecessary physical pain, and the undermining of people’s right to health. Some would argue that the threat of drugs to society may justify some level of abrogation of human rights for protection of collective security, as is also foreseen by human rights law in case of emergencies. International human rights standards dictate that in such cases, societies still must choose the least harmful way to address the emergency and that emergency measures must be proportionate and designed specifically to meet transparently defined and realistic goals. The pursuit of drug prohibition meets none of these criteria. Standard public health and scientific approaches that should be part of policy-making on drugs have been rejected in the pursuit of prohibition. The idea of reducing the harm of many kinds of human behavior is central to public policy in the areas of traffic safety, tobacco and alcohol regulation, food safety, safety in sports and recreation, and many other areas of human life where the behavior in question is not prohibited. But explicitly seeking to reduce drug-related harms through policy and programmes and to balance prohibition with harm reduction is regularly resisted in drug control. The persistence of unsafe injection-linked HIV and HCV transmission that could be stopped with proven, cost-effective measures remains one of the great failures of the global responses to these diseases. Drug policy that is dismissive of extensive evidence of its own negative impact and of approaches that could improve health outcomes is bad for all concerned. Countries have failed to recognise and correct the health and human rights harms that pursuit of prohibition and drug suppression have caused and in so doing neglect their legal responsibilities. They readily incarcerate people for minor offenses but then neglect their duty to provide health services in custodial settings. They recognize uncontrolled illegal markets as the consequence of their policies, but they do little to protect people from toxic, adulterated drugs that are inevitable in illegal markets or the violence of organized criminals, often made worse by policing. They waste public resources on policies that do not demonstrably impede the functioning of drug markets, and they miss opportunities to invest public resources wisely in proven health services for people often too frightened to seek services. To move toward the balanced policy that UN member states have called for, we offer the following recommendations: Decriminalisation: Decriminalise minor, non-violent drug offenses – use, possession, and petty sale – and strengthen health and social-sector alternatives to criminal sanctions. Reducing violence and discrimination in policing: Reduce the violence and other harms of drug policing, including phasing out the use of military forces in drug policing, better targeting of policing on the most violent armed criminals, allowing possession of syringes, not targeting harm reduction services to boost arrest totals, and eliminating racial and ethnic discrimination in policing. Reducing harms: Ensure easy access for all who need them to harm reduction services as a part of responding to drugs, recognizing the effectiveness and cost-effectiveness of scaling up and sustaining these services. OST, NSP, supervised injection sites, and access to naloxone – brought to a scale adequate to meet demand – should all figure in health services and should include meaningful participation of PWUD in planning and implementation. Harm reduction services are crucial in prison and pretrial detention and should be scaled up in these settings. The 2016 UNGASS should do better than the UN Commission on Narcotic Drugs (CND) in naming harm reduction explicitly and endorsing its centrality to drug policy. Treatment and care for PWUD: Prioritize PWUD in treatment for HIV, HCV, TB, and ensure that services are adequate to ensure access for all who need care. Ensure availability of humane and scientifically sound treatment for drug dependence, including scaled-up OST in the community as well as in prisons, rejecting compulsory detention and abuse in the name of treatment. Access to controlled medicines: Ensure access to controlled medicines, establishing inter-sectoral national authorities to determine levels of need and giving the World Health Organization (WHO) the resources to assist the International Narcotics Control Board (INCB) in using the best science to determine the level of need for controlled medicines in all countries. Gender-responsive policies: Reduce the negative impact of drug policy and law on women and their families, especially minimizing custodial sentences for women who commit non-violent offenses and developing appropriate health and social support, including gender-appropriate treatment of drug dependence, for those who need it. Crop production: Efforts to address drug crop production must take health into account. Aerial spraying of toxic herbicides should be stopped, and alternative development programmes should be part of integrated development strategies, developed and implemented in meaningful consultation with the people affected. Improve research: There is a need for a more diverse donor base to fund the best new science on drug policy experiences in a non-ideological way that, among other things, interrogates and moves beyond the excessive pathologising of drug use. UN governance of drug control: UN governance of drug policy must be improved, including by respecting WHO’s authority to determine the dangerousness of drugs. Countries should be urged to include high-level health officials in their delegations to CND. Improved representation of health officials in national delegations to CND would, in turn, be a likely result of giving health authorities an important day-to-day role in multi-sectoral national drug policy-making bodies. Better metrics: Health, development, and human rights indicators should be included in metrics to judge success of drug policy; WHO and UNDP should help formulate them. UNDP has already suggested that indicators such as access to treatment, rate of overdose deaths, and access to social welfare programmes for people who use drugs would be useful indicators. All drug policies should also be monitored and evaluated as to their impact on racial and ethnic minorities, women, children and young people, and people living in poverty. Scientific approach to regulated markets: Move gradually toward regulated drug markets and apply the scientific method to their evaluation. While regulated legal drug markets are not politically possible in the short term in some places, the harms of criminal markets and other consequences of prohibition catalogued in this report are likely to lead more countries (and more US states) to move gradually in that direction, a direction we endorse. As those decisions are taken, we urge governments and researchers to apply the scientific method and ensure independent, multidisciplinary and rigorous evaluation of regulated markets to draw lessons and inform improvements in regulatory practices, and to continue evaluating and improving. We urge health professionals in all countries to inform themselves and join debates on drug policy at all levels. True to the stated goals of the international drug control regime, it is possible to have drug policy that contributes to the health and well-being of humankind, but not without bringing to bear the evidence of the health sciences and the voices of health professionals.
METHODS: We investigated serum creatinine (S-Cr) monitoring rates before and during ART and the incidence and prevalence of renal dysfunction after starting TDF by using data from a regional cohort of HIV-infected individuals in the Asia-Pacific. Time to renal dysfunction was defined as time from TDF initiation to the decline in estimated glomerular filtration rate (eGFR) to <60 ml/min/1.73m2 with >30% reduction from baseline using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation or the decision to stop TDF for reported TDF-nephrotoxicity. Predictors of S-Cr monitoring rates were assessed by Poisson regression and risk factors for developing renal dysfunction were assessed by Cox regression.
RESULTS: Among 2,425 patients who received TDF, S-Cr monitoring rates increased from 1.01 to 1.84 per person per year after starting TDF (incidence rate ratio 1.68, 95%CI 1.62-1.74, p <0.001). Renal dysfunction on TDF occurred in 103 patients over 5,368 person-years of TDF use (4.2%; incidence 1.75 per 100 person-years). Risk factors for developing renal dysfunction included older age (>50 vs. ≤30, hazard ratio [HR] 5.39, 95%CI 2.52-11.50, p <0.001; and using PI-based regimen (HR 1.93, 95%CI 1.22-3.07, p = 0.005). Having an eGFR prior to TDF (pre-TDF eGFR) of ≥60 ml/min/1.73m2 showed a protective effect (HR 0.38, 95%CI, 0.17-0.85, p = 0.018).
CONCLUSIONS: Renal dysfunction on commencing TDF use was not common, however, older age, lower baseline eGFR and PI-based ART were associated with higher risk of renal dysfunction during TDF use in adult HIV-infected individuals in the Asia-Pacific region.
FINDINGS: A malaria survey spanning 7 years (2006 - 2012) was conducted in Selangor. A total of 1623 laboratory confirmed malaria cases were reported from Selangor's nine districts. While 72.6% of these cases (1178/1623) were attributed to imported malaria (cases originating from other countries), 25.5% (414/1623) were local cases and 1.9% (31/1623) were considered as relapse and unclassified cases combined. In this study, the most prevalent infection was P. vivax (1239 cases, prevalence 76.3%) followed by P. falciparum (211, 13.0%), P. knowlesi (75, 4.6%), P. malariae (71, 4.4%) and P. ovale (1, 0.06%). Mixed infections comprising of P. vivax and P. falciparum were confirmed (26, 1.6%). Entomological surveys targeting the residences of malaria patients' showed that the most commonly trapped Anopheles species was An. maculatus. No oocysts or sporozoites were found in the An. maculatus collected. Nevertheless, the possibility of An. maculatus being the malaria vector in the investigated locations was high due to its persistent occurrence in these areas.
CONCLUSIONS: Malaria cases reported in this study were mostly imported cases. However the co-existence of local cases and potential Plasmodium spp. vectors should be cause for concern. The results of this survey reflect the need of maintaining closely monitored malaria control programs and continuous extensive malaria surveillance in Peninsula Malaysia.
METHODS: Prospectively collected longitudinal data from patients in Thailand, Hong Kong, Malaysia, Japan, Taiwan, and South Korea were provided for analysis. Covariates included demographics, hepatitis B and C coinfections, baseline CD4 T lymphocyte count, and plasma HIV-1 RNA levels. Clinical deterioration (a new diagnosis of Centers for Disease Control and Prevention category B/AIDS-defining illness or death) was assessed by proportional hazards models. Surrogate endpoints were 12-month change in CD4 cell count and virologic suppression post therapy, evaluated by linear and logistic regression, respectively.
RESULTS: Of 1105 patients, 1036 (93.8%) infected with CRF01_AE or subtype B were eligible for inclusion in clinical deterioration analyses and contributed 1546.7 person-years of follow-up (median: 413 days, interquartile range: 169-672 days). Patients >40 years demonstrated smaller immunological increases (P = 0.002) and higher risk of clinical deterioration (hazard ratio = 2.17; P = 0.008). Patients with baseline CD4 cell counts >200 cells per microliter had lower risk of clinical deterioration (hazard ratio = 0.373; P = 0.003). A total of 532 patients (48.1% of eligible) had CD4 counts available at baseline and 12 months post therapy for inclusion in immunolgic analyses. Patients infected with subtype B had larger increases in CD4 counts at 12 months (P = 0.024). A total of 530 patients (48.0% of eligible) were included in virological analyses with no differences in response found between genotypes.
CONCLUSIONS: Results suggest that patients infected with CRF01_AE have reduced immunologic response to therapy at 12 months, compared with subtype B-infected counterparts. Clinical deterioration was associated with low baseline CD4 counts and older age. The lack of differences in virologic outcomes suggests that all patients have opportunities for virological suppression.
METHODS: The study population consisted of HIV-infected patients enrolled in the TREAT Asia HIV Observational Database (TAHOD). Individuals were included in this analysis if they started combination antiretroviral treatment (cART) after 2002, were being treated at a centre that documented a median rate of viral load monitoring ≥0.8 tests/patient/year among TAHOD enrolees, and experienced a minor or major treatment substitution while on virally suppressive cART. The primary endpoint to evaluate outcomes was clinical or virological failure (VF), followed by an ART class change. Clinical failure was defined as death or an AIDS diagnosis. VF was defined as confirmed viral load measurements ≥400 copies/mL followed by an ART class change within six months. Minor regimen substitutions were defined as within-class changes and major regimen substitutions were defined as changes to a drug class. The patterns of substitutions and rate of clinical or VF after substitutions were analyzed.
RESULTS: Of 3994 adults who started ART after 2002, 3119 (78.1%) had at least one period of virological suppression. Among these, 1170 (37.5%) underwent a minor regimen substitution, and 296 (9.5%) underwent a major regimen substitution during suppression. The rates of clinical or VF were 1.48/100 person years (95% CI 1.14 to 1.91) in the minor substitution group, 2.85/100 person years (95% CI 1.88 to 4.33) in the major substitution group and 2.53/100 person years (95% CI 2.20 to 2.92) among patients that did not undergo a treatment substitution.
CONCLUSIONS: The rate of clinical or VF was low in both major and minor substitution groups, showing that regimen substitution is generally effective in non-clinical trial settings in Asian countries.
METHODS: Patient data from 2003-2017 were obtained from the Therapeutics, Research, Education and AIDS Training in Asia (TREAT Asia) HIV Observational Database (TAHOD). We included patients on antiretroviral therapy (ART) with > 1 day of follow-up. Cumulative incidences were plotted for CVD-related, AIDS-related, non-AIDS-related, and unknown CODs, and any CVD (i.e. fatal and nonfatal). Competing risk regression was used to assess risk factors of any CVD.
RESULTS: Of 8069 patients with a median follow-up of 7.3 years [interquartile range (IQR) 4.4-10.7 years], 378 patients died [incidence rate (IR) 6.2 per 1000 person-years (PY)], and this total included 22 CVD-related deaths (IR 0.36 per 1000 PY). Factors significantly associated with any CVD event (IR 2.2 per 1000 PY) were older age [sub-hazard ratio (sHR) 2.21; 95% confidence interval (CI) 1.36-3.58 for age 41-50 years; sHR 5.52; 95% CI 3.43-8.91 for ≥ 51 years, compared with < 40 years], high blood pressure (sHR 1.62; 95% CI 1.04-2.52), high total cholesterol (sHR 1.89; 95% CI 1.27-2.82), high triglycerides (sHR 1.55; 95% CI 1.02-2.37) and high body mass index (BMI) (sHR 1.66; 95% CI 1.12-2.46). CVD crude IRs were lower in the later ART initiation period and in lower middle- and upper middle-income countries.
CONCLUSIONS: The development of fatal and nonfatal CVD events in our cohort was associated with older age, and treatable risk factors such as high blood pressure, triglycerides, total cholesterol and BMI. Lower CVD event rates in middle-income countries may indicate under-diagnosis of CVD in Asian-Pacific resource-limited settings.
METHODS: We analyzed patients from the Adult Dengue Platelet Study with laboratory-confirmed dengue with ≤20 000 platelets/μL and without persistent mild bleeding or any severe bleeding in a post hoc analysis. Poor platelet recovery was defined as a platelet count of ≤20 000/μL on Day 2. We recruited 372 participants from 5 acute care hospitals located in Singapore and Malaysia between 29 April 2010 and 9 December 2014. Of these, 188 were randomly assigned to the transfusion group and 184 to the control group.
RESULTS: Of 360 patients, 158 had poor platelet recovery. Age, white cell count, and day of illness at study enrollment were significant predictors of poor platelet recovery after adjustment for baseline characteristics and platelet transfusion. Patients with poor platelet recovery had longer hospitalizations but no significant difference in other clinical outcomes, regardless of transfusion. We found a significant interaction between platelet recovery and transfusion; patients with poor platelet recovery were more likely to bleed if given a prophylactic platelet transfusion (odds ratio 2.34, 95% confidence interval 1.18-4.63).
CONCLUSIONS: Dengue patients with thrombocytopenia who were older or presented earlier and with lower white cell counts were more likely to have poor platelet recovery. In patients with poor platelet recovery, platelet transfusion does not improve outcomes and may actually increase the risk of bleeding. The mechanisms of poor platelet recovery need to be determined.
CLINICAL TRIALS REGISTRATION: NCT01030211.
METHODS: Long-term LTFU was defined as LTFU occurring after 5 years on ART. LTFU was defined as (1) patients not seen in the previous 12 months; and (2) patients not seen in the previous 6 months. Factors associated with LTFU were analysed using competing risk regression.
RESULTS: Under the 12-month definition, the LTFU rate was 2.0 per 100 person-years (PY) [95% confidence interval (CI) 1.8-2.2 among 4889 patients included in the study. LTFU was associated with age > 50 years [sub-hazard ratio (SHR) 1.64; 95% CI 1.17-2.31] compared with 31-40 years, viral load ≥ 1000 copies/mL (SHR 1.86; 95% CI 1.16-2.97) compared with viral load < 1000 copies/mL, and hepatitis C coinfection (SHR 1.48; 95% CI 1.06-2.05). LTFU was less likely to occur in females, in individuals with higher CD4 counts, in those with self-reported adherence ≥ 95%, and in those living in high-income countries. The 6-month LTFU definition produced an incidence rate of 3.2 per 100 PY (95% CI 2.9-3.4 and had similar associations but with greater risks of LTFU for ART initiation in later years (2006-2009: SHR 2.38; 95% CI 1.93-2.94; and 2010-2011: SHR 4.26; 95% CI 3.17-5.73) compared with 2003-2005.
CONCLUSIONS: The long-term LTFU rate in our cohort was low, with older age being associated with LTFU. The increased risk of LTFU with later years of ART initiation in the 6-month analysis, but not the 12-month analysis, implies that there was a possible move towards longer HIV clinic scheduling in Asia.
METHODS: PLHIV enrolled in the Therapeutics, Research, Education and AIDS Training in Asia (TREAT Asia) HIV Observational Database (TAHOD) who initiated ART with a CD4 count 1 year were censored at 12 months. Competing risk regression was used to analyse risk factors with loss to follow-up as a competing risk.
RESULTS: A total of 1813 PLHIV were included in the study, of whom 74% were male. With 73 (4%) deaths, the overall first-year mortality rate was 4.27 per 100 person-years (PY). Thirty-eight deaths (52%) were AIDS-related, 10 (14%) were immune reconstituted inflammatory syndrome (IRIS)-related, 13 (18%) were non-AIDS-related and 12 (16%) had an unknown cause. Risk factors included having a body mass index (BMI) 100 cells/μL: SHR 0.12; 95% CI 0.05-0.26) was associated with reduced hazard for mortality compared to CD4 count ≤ 25 cells/μL.
CONCLUSIONS: Fifty-two per cent of early deaths were AIDS-related. Efforts to initiate ART at CD4 counts > 50 cell/μL are associated with improved short-term survival rates, even in those with late stages of HIV disease.
METHODS: Logistic regression analysis was used to distinguish associated current smoking characteristics. Five-year predictive risks of CVD, CHD and MI and the impact of simulated interventions were calculated utilizing the Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D) algorithm.
RESULTS: Smoking status data were collected from 4274 participants and 1496 of these had sufficient data for simulated intervention calculations. Current smoking prevalence in these two groups was similar (23.2% vs. 19.9%, respectively). Characteristics associated with current smoking included age > 50 years compared with 30-39 years [odds ratio (OR) 0.65; 95% confidence interval (CI) 0.51-0.83], HIV exposure through injecting drug use compared with heterosexual exposure (OR 3.03; 95% CI 2.25-4.07), and receiving antiretroviral therapy (ART) at study sites in Singapore, South Korea, Malaysia, Japan and Vietnam in comparison to Thailand (all OR > 2). Women were less likely to smoke than men (OR 0.11; 95% CI 0.08-0.14). In simulated interventions, smoking cessation demonstrated the greatest impact in reducing CVD and CHD risk and closely approximated the impact of switching from abacavir to an alternate antiretroviral in the reduction of 5-year MI risk.
CONCLUSIONS: Multiple interventions could reduce CVD, CHD and MI risk in Asian HIV-positive patients, with smoking cessation potentially being the most influential.